Choice of hospital for delivery: a comparison of high-risk and low-risk women. (49/55)

OBJECTIVE: This article tests whether or not the factors that affect hospital choice differ for selected subgroups of the population. DATA SOURCES: 1985 California Office of Statewide Health Planning and Development (OSHPD) discharge abstracts and hospital financial data were used. STUDY DESIGN: Models for hospital choice were estimated using McFadden's conditional logit model. Separate models were estimated for high-risk and low-risk patients, and for high-risk and low-risk women covered either by private insurance or by California Medicaid. The model included independent variables to control for quality, price, ownership, and distance to the hospital. DATA EXTRACTION: Data covered all maternal deliveries in the San Francisco Bay Area in 1985 (N = 61,436). ICD-9 codes were used to classify patients as high-risk or low-risk. The expected payment code on the discharge abstract was used to identify insurance status. PRINCIPAL FINDINGS: The results strongly reject the hypothesis that high-risk and low-risk women have the same choice process. Hospital quality tended to be more important for high-risk than low-risk women. These results also reject the hypothesis that factors influencing choice of hospital are the same for women covered by private insurance as for those covered by Medicaid. Further, high-risk women covered by Medicaid were less likely than high-risk women covered by private insurance to deliver in hospitals with newborn intensive care units. CONCLUSIONS: The results show that the choice factors vary across several broadly defined subgroups of patients with a specific condition. Thus, estimates aggregating all patients may be misleading. Specifically, such estimates will understate actual patient response to quality of care indicators, since patient sensitivity to quality of care varies with the patients' risk status.  (+info)

The costs of visits to emergency departments. (50/55)

BACKGROUND: Many visits to emergency departments are for minor medical problems, and these visits are criticized as being expensive and economically inefficient. This study examines the marginal costs (the extra costs for an additional visit) of emergency department visits. METHODS: Monthly data on the costs of hospital and physicians' services from 1991 through 1993 were obtained from a sample of six community hospitals in Michigan. The data were analyzed with ordinary least-squares regression techniques to determine the ratio of marginal to average costs. Average and marginal costs were then determined for 24,010 visits during 12 randomly selected weeks in 1993. A visit by an individual patient was the unit analysis, and visits were classified as nonurgent, semiurgent, or urgent according to explicit criteria. Costs and charges were determined for all visits and were classified according to the degree of urgency. RESULTS: For all emergency department visits, the average charge was $383, the average cost was $209, and the marginal cost was $88 (42 percent of the average cost). Thirty-two percent of the visits were classified as nonurgent, 26 percent as semiurgent, and 42 percent as urgent. For nonurgent visits, the average charge was $124, the average cost was $62, and the marginal cost was only $24. For semiurgent visits, the average charge was $312, the average cost was $159, and the marginal cost was $67. For urgent visits, the average charge was $621, the average cost was $351, and the marginal cost was $148. CONCLUSIONS: The true costs of nonurgent care in the emergency department are relatively low. The potential savings from a diversion of nonurgent visits to private physicians' offices may therefore be much less than is widely believed.  (+info)

Use of alternative techniques of hysterectomy in Ohio, 1988-1994. (51/55)

BACKGROUND: Laparoscopically assisted vaginal hysterectomy has been promoted as a substitute for both abdominal and vaginal hysterectomy, with claimed benefits of lower costs, shorter hospital stays, and quicker postoperative recovery. METHODS: Using computerized hospital-discharge data for 1988-1994 from 180 hospitals in Ohio, we analyzed rates of abdominal, vaginal, and laparoscopically assisted vaginal hysterectomy and their association with characteristics of patients, complications, in-hospital mortality, and hospital charges. RESULTS: The annual age-adjusted rate of hysterectomy fell 10 percent, from 4.53 per 1000 female state residents in 1988 to 4.07 per 1000 in 1994 (P<0.001). In 1988, 1.1. percent of all hysterectomies were performed by the laparoscopically assisted vaginal technique; this proportion increased to 9.2 percent in 1993 and declined to 7.5 percent in 1994. For gynecologic conditions other than cancer or pregnancy, women undergoing laparoscopically assisted vaginal hysterectomy as compared with one of the other techniques were more likely to have commercial insurance and to have their surgery at an urban hospital for diagnoses related to pain, endometriosis, or pelvic inflammatory disease. With abdominal and laparoscopically assisted vaginal hysterectomy, the complication rates were similar and were higher than those with vaginal hysterectomy. In-hospital mortality was similar for vaginal and laparoscopically assisted vaginal hysterectomy and was lower than for abdominal hysterectomy. Median hospital charges were $8,108 for laparoscopically assisted vaginal hysterectomy, $5,723 for abdominal hysterectomy, and $5,049 for vaginal hysterectomy. CONCLUSIONS: The rate of hysterectomy in Ohio decreased from 1988 to 1994, as laparoscopically assisted vaginal hysterectomy became more common. Laparoscopically assisted vaginal hysterectomy was associated with higher hospital charges than the other techniques.  (+info)

US emergency department costs: no emergency. (52/55)

BACKGROUND: Many perceive emergency department (ED) overuse as an important cause of high medical care costs in the United States. Managed care plans and politicians have seen constraints on ED use as an important element of cost control. METHODS: We measured ED-associated and other medical care costs, using the recently released 1987 National Medical Expenditure Survey of approximately 35,000 persons in 14,000 households representative of the US civilian, noninstitutionalized population. RESULTS: In 1987, total ED expenditures were $8.9 billion, or 1.9% of national health expenditures. People with health insurance represented 86% of the population and accounted for 88% of ED spending. The uninsured paid 47% of ED costs themselves; free care covered only 10%. For the uninsured, the cost of hospitalization initiated by ED visits totaled $3.3 billion, including $1.1 billion in free care. Whites accounted for 75% of total ED costs. The ED costs of poor and near-poor individuals accounted for only 0.47% of national health costs. CONCLUSIONS: ED use accounts for a small share of US medical care costs, and cost shifting to the insured to cover free ED care for the uninsured is modest. Constraining ED use cannot generate substantial cost savings but may penalize minorities and the poor, who receive much of their outpatient care in EDs.  (+info)

Elderly veterans receiving care at a Veterans Affairs Medical Center while enrolled in Medicare-financed HMOs. Is the taxpayer paying twice? (53/55)

Elderly veterans who visit our Veterans Affairs (VA) Medical Center primary care clinic often mention they are enrolled in HMOs. Approximately 20% of patients hospitalized at our facility report health insurance coverage. Of 1,000 hospitalizations during a 6-month period in which veterans reported insurance coverage, 337 involved elderly veterans. Of these 337 hospitalizations, 218 (65%) were for 174 veterans who stated they were enrolled in a Medicare-financed HMO. The VA's Medical Care Cost Recovery Program deemed only 46 (21%) of the hospitalizations billable and received reimbursement for 20 (9%). Thus, the VA is providing costly services already paid for by the Health Care Financing Administration under prepaid capitation contracts, and recovers minimal reimbursement from the HMOs.  (+info)

Another look at emergency room overcrowding: accessibility of the health services and quality of care. (54/55)

PURPOSE: To describe both the social characteristics and the health needs of the medical users of a pediatric hospital Emergency Room with special emphasis on frequent use. STUDY SELECTION: Observational study on health services utilization and health care needs of young children consulting at a teaching hospital's Emergency Room. DATA SOURCES: Mother interview and medical record review. RESULTS OF DATA SYNTHESIS: Children from underprivileged strata are more often high Emergency Room users. Their preventive needs are satisfied but adequate follow-up of their medical problems is more often lacking. CONCLUSION: To understand why some achievable benefits are not achieved it is necessary to evaluate the varying performance of health services according to the social origin of the users.  (+info)

Insurance type and choice of hospital for coronary artery bypass graft surgery. (55/55)

OBJECTIVE: To examine the effect of insurance type on the relationship between hospital attributes and patient flows, with particular attention to whether HMO enrollees are more or less likely than other patients to receive care at high-quality hospitals and whether HMO enrollees travel farther to receive care. DATA SOURCES/STUDY SETTING: Data on patient flows, taken from discharge abstracts compiled by the California Office of Statewide Health Planning and Development. Our sample consists of patients undergoing coronary artery bypass graft surgery (CABG) in 1991 who resided in three California markets. Only patients under the age of 65 and insured by HMOs, Blue Cross/Blue Shield, or other commercial insurance were included. Hospital quality is based on hospital-specific measures of excess mortality from CABG. Other hospital attributes were taken from American Hospital Association survey data. STUDY DESIGN: Conditional-choice models were used to estimate the probability that patients would receive care at any given hospital as a function of their insurance type and the hospital's attributes. PRINCIPAL FINDINGS: Patients were more likely to receive care from hospitals closer to their residence. However, HMO patient flows were less sensitive to proximity. In general, the likelihood that an HMO enrollee received care at a given hospital was positively related to hospital quality. Moreover, quality had a greater effect on patient flows for HMO enrollees than for non-HMO enrollees. However, the evidence suggests that the effect of quality on patient flows is neither uniform across markets nor across HMOs. CONCLUSIONS: HMOs do not appear to direct patients to low-quality hospitals. However, heterogeneity among HMOs and across markets suggests that buyers must recognize that choosing an HMO involves greater scrutiny than simply picking a plan labeled "HMO."  (+info)